HospitalInspections.org

Based on record review and interview the facility staff failed to ensure the nursing staff perform pain reassessments after giving a pain medication intervention to ensure safe and effective pain management in 5 of 10 medical records reviewed (Patient (Pt) #1, 4, 5, 8, 9), in a total sample of 10 medical records reviewed.

Findings Include:

Review of policy and procedure 3.5.5 titled, "Pain Management: Screening, Assessment, and Reassessment" effective date August 5, 2020 revealed:
- "Following an intervention, the patient should be reassessed for pain relief, side effects, or other adverse event produced by the intervention."
- "Reassessment of pain is ongoing. Reassess after each intervention and with each additional report of pain in a timely and comprehensive manner appropriate to the circumstances to ensure safety and efficacy."
- "Patients that can verbalize pain or answer question independently...should have a comprehensive pain assessment. Assessments components may include: a. Quality, onset, location, duration...d. An acceptable level of pain...e. Intensity of the patient's pain rating on a scale (e.g.,0 to 10, mild-moderate-severe)."
- "The minimum documentation of a comprehensive pain assessment includes: Frequency, Location, Intensity, and Quality."

Review of Pt #1's medical record revealed Pt #1 was admitted to the hospital on 09/15/2025 for Laparoscopic Distal Pancreatomy (partial removal of the pancreas) and Splenectomy (removal of the spleen); Pt #1 was discharged home on 09/20/2025 at 2:50 PM.

Review of Pt #1's pain medication orders revealed Hydromophone (Dilaudid) 2-4 milligrams (mg) PO (by mouth) every 4 hours PRN (as needed) for pain. Pt #1 was on a continuous Dilaudid Epidural Nerve Block infusion from 09/15/2025 until it was stopped on 09/19/2025 at 11:26 AM.

Review of Pt #1's Medication Administration Record and Pain assessment flow sheets revealed:
-On 09/19/2025 Pt #1 was given Dilaudid 2 mg PO at 11:03 AM and the Dilaudid Epidural infusion was stopped at 11:26 AM. There was no documented evidence of nursing staff completing a pain assessment/reassessment to ensure the medication intervention was safe and effective until 9:00 PM, 9 hours and 57 minutes later.
-On 09/19/2025 Pt #1 was given Dilaudid 2 mg PO at 3:29 PM. There was no documented evidence of nursing staff completing a pain assessment/reassessment until 9:00 PM, 5 hours and 31 minutes later.
-On 09/20/2025 Pt #1 was given Dilaudid 2 mg PO at 12:57 AM. There was no documented evidence of staff completing a pain reassessment until 9:00 AM, 8 hours and 3 minutes later.
-On 09/20/2025 Pt #1 was given Dilaudid 4 mg at 5:37 AM. There was no documented evidence of staff completing a pain assessment and reassessment until 9:00 AM, 5 hours and 23 minutes later.

Review of Pt #4's medical record revealed Pt #4 was admitted to the hospital on 11/30/2025 with Leukocytosis (abnormally high white blood cells), Sepsis (blood infection), and Polycystic Kidney Disease; Pt #4 was a current patient at the time of medical record review.

Review of Pt #4's Medication Administration Record and Pain assessment flow sheets revealed:
-On 12/01/2025 Pt #4 was given Oxycodone (narcotic pain medication) 10 mg PO at 10:13 AM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 3:00 PM, 4 hours and 47 minutes later.
-On 12/01/2025 Pt #4 was given Oxycodone 10 mg PO at 10:56 PM. There was no documented evidence of nursing staff completing a pain reassessment until 12/02/2025 at 5:15 AM, 6 hours and 19 minutes later.
-On 12/02/2025 Pt #4 was given Oxycodone 10 mg PO at 8:21 AM. There was no documented evidence of nursing staff completing a pain reassessment until 3:00 PM, 6 hours and 39 minutes later.
-On 12/02/2025 Pt #4 was given Oxycodone 10 mg PO at 9:21 PM. There was no documented evidence of nursing staff completing a pain reassessment until 7:45 AM, 10 hours and 24 minutes later.

Review of Pt #5's medical record revealed Pt #5 was admitted to the hospital on 12/01/2025 for a hernia repair and breast reconstruction post mastectomy; Pt #5 was a current patient at the time of medical record review.

Review of Pt #5's Medication Administration Record and Pain assessment flow sheets revealed:
-On 12/02/2025 Pt #5 was given Oxycodone 10 mg PO at 1:18 AM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 8:30 AM, 7 hours and 12 minutes later.
-On 12/02/2025 Pt #5 was given Oxycodone 10 mg PO at 4:26 PM. There was no documented evidence of nursing staff completing a pain reassessment until 9:00 PM, 4 hours and 34 minutes later.

Review of Pt #8's medical record revealed Pt #8 was admitted to the hospital on 10/01/2025 due to a motor vehicle accident; Pt #8 was discharged on 10/06/2025 at 1:00 PM.

Review of Pt #8's Medication Administration Record and Pain assessment flow sheets revealed:
-On 10/02/2025 Pt #8 was given Intravenous (IV) Dilaudid 0.4 mg at 2:05 AM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 6:00 AM, 3 hours and 55 minutes later.
-On 10/02/2025 Pt #8 was given Intravenous (IV) Dilaudid 0.4 mg at 9:51 AM. There was no documented evidence of nursing staff completing a pain reassessment until 3:45 PM, 5 hours and 54 minutes later.

Review of Pt #9's medical record revealed Pt #9 was admitted to the hospital on 08/25/2025 due to hip pain; Pt #10 was discharged on 08/26/2025 at 5:20 PM.

Review of Pt #9's Medication Administration Record and Pain assessment flow sheets revealed:
-On 08/25/2025 Pt #9 was given Oxycodone 10 mg PO at 4:40 PM. There was no documented evidence of nursing staff completing a pain reassessment to ensure the medication intervention was safe and effective until 9:00 PM, 4 hours and 20 minutes later.
-On 08/25/2025 Pt #9 was given Oxycodone 10 mg PO at 2:17 AM. There was no documented evidence of nursing staff completing a pain reassessment until 6:17 AM, 4 hours later.

Per interview with Nurse Manager D (Acute Care) on 12/04/2025 beginning at 10:54 AM, Manager D stated that nursing staff should do a comprehensive pain reassessment within an hour after giving a pain medication intervention. Manager D stated that staff should document interventions in the medical record. Manager D stated that she expects the staff to follow the Pain Management policy.